Which should go first during same-day bidirectional endosocopy with propofol sedation?

Background and Aim: Same-day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy, is frequently performed to screen for cancer and gastrointestinal bleeding. However, the optimal sequence for the procedures is unclear thus far. The aim of this study was to evaluate the optimal sequence for same-day bidirectional endoscopy. Methods: Consecutive patients undergoing same-day bidirectional endoscopy under propofol sedation were randomized to either the colonoscopy-first group (colonoscopy followed by EGD, n=87) or the EGD-first group (EGD followed by colonoscopy, n=89). We evaluated the propofol dose, procedure duration, patient tolerance and recovery, adverse events, and endoscopic findings. The patient tolerance was assessed with a 0-10 visual analog scale. Results: Total procedure times, patients' tolerance and recovery, adverse events, and endoscopic findings were similar between the two groups. The total propofol dose was significantly higher for the colonoscopy-first group than for the EGD-first group (mean 95% credibility limit: 135.7 [70-201.4]mg vs 124.7 [64.1-185.3]mg, respectively, P=0.024). Patients in the colonoscopy-first group moved significantly more during colonoscopy than those in the EGD-first group: 1.1 (0-3.8) versus 0.6 (0-2.9) scores, respectively (P=0.024). Conclusion: The optimal sequence for same-day bidirectional endoscopy is EGD followed by colonoscopy. In this order, the procedure is better tolerated, and patients require a lower overall dose of propofol.